Purpose The objective of this study is to identify how predisposing characteristics, enabling factors, and health needs are jointly and individually associated with epidemiological patterns of outpatient healthcare utilization for patients who already interact and engage with a large healthcare system. Methods We retrospectively analyzed electronic medical record data from 1,423,166 outpatient clinic visits from 474,674 patients in a large healthcare system from June 2018-March 2019. We evaluated patients who exclusively visited rural clinics versus patients who exclusively visited urban clinics using Chi-square tests and the generalized estimating equation Poisson regression methodology. The outcome was healthcare use defined by the number of outpatient visits to clinics within the healthcare system and independent variables included age, gender, race, ethnicity, smoking status, health status, and rural or urban clinic location. Supplementary analyses were conducted observing healthcare use patterns within rural and urban clinics separately and within primary care and specialty clinics separately. Findings Patients in rural clinics vs. urban clinics had worse health status [χ2 = 935.1, df = 3, p<0.0001]. Additionally, patients in rural clinics had lower healthcare utilization than patients in urban clinics, adjusting for age, race, ethnicity, gender, smoking, and health status [2.49 vs. 3.18 visits, RR = 0.61, 95%CI = (0.55,0.68), p<0.0001]. Further, patients in rural clinics had lower utilization for both primary care and specialty care visits. Conclusions Within the large healthcare system, patients in rural clinics had lower outpatient healthcare utilization compared to their urban counterparts despite having potentially elevated health needs reflected by a higher number of unique health diagnoses documented in their electronic health records after adjusting for multiple factors. This work can inform future studies exploring the roots and ramifications of rural-urban healthcare utilization differences and rural healthcare disparities.